Acute respiratory failure following lithium intoxication

Two patients suffering from severe lithium poisoning (blood level greater than 4 mmol/litre) were treated by haemodialysis. Both patients developed delayed respiratory failure, with the characteristics of adult respiratory distress syndrome, at a time when lithium levels had fallen below 2 mmol/litre. We recommend early respiratory support in the treatment of severe lithium intoxication.     

A hypothesis linking sodium and lithium reabsorption in the distal nephron.

BACKGROUND: A hypothesis is proposed linking Na(+) and Li(+) reabsorption in the distal nephron. The handling of these two ions in the distal nephron is related because they share the same apical membrane entry mechanism: the amiloride-sensitive Na(+) channel (ENaC). However, the two ions exit the cell through different transport mechanisms: Na(+) via the Na(+)-K(+)-ATPase and Li(+) via the Na(+)/H(+) exchanger. Studies in rats have shown that under normal circumstances hardly any Li(+) is reabsorbed in the distal nephron, so that the urinary excretion of Li(+), expressed as a fraction of the delivery to the early distal tubule (FE(Li dist)), amounts to approximately 0.97. In contrast, during severe dietary Na(+) restriction, FE(Li dist) decreases to 0.50-0.60. Our hypothesis is that the absence of distal Li(+) reabsorption during intake of a normal diet can be explained by a negative driving force for Li(+) entrance across the apical membrane in those segments in which ENaC is active. METHOD: We propose a model that incorporates this concept. RESULTS: The model indicates that the lowering of FE(Li dist) during dietary Na(+) restriction can be explained by activation of apical ENaC in extra sub-segments further downstream. In these extra sub-segments the driving force for Li(+) reabsorption is positive, leading to significant Li(+) reabsorption. During dietary K(+) restriction, FE(Li dist) is reduced to 0.35-0.55. The model shows that this reduction in FE(Li dist) can be explained by hyperpolarization of the apical membrane in ENaC-containing sub-segments, which is known to occur in this condition. CONCLUSION: We conclude that the model may improve current understanding of both Na(+) and Li(+) handling in the distal nephron.     

Traumatic brain injury: intensive care management

Traumatic brain injury (TBI) is a major cause of morbidity andmortality worldwide. The modern management of severe TBI hasfallen into the domain of a multidisciplinary team led by neurointensivists,neuroanaesthetists, and neurosurgeons and is based on the avoidanceof secondary injury, maintenance of cerebral perfusion pressure(CPP), and optimization of cerebral oxygenation. In this review,we will discuss the intensive care management of severe TBIwith emphasis on the specific measures directed at the controlof intracranial pressure and CPP.     

软组织平衡在全髋关节置换术治疗成人高位髋关节发育不良中的应用

目的 评价软组织平衡技术在全髋关节置换术治疗成人高位髋关节发育不良的效果.方法 2000年12月至2006年8月应用全髋关节置换术治疗21例(26髋)高位髋关节发育不良患者(CreweⅢ型20髋;Ⅳ型6髋).通过软组织松解及股骨转子下短缩截骨重建髋臼于真臼水平,评价其术后临床及影像学结果.术前Harris评分平均41.2分.结果 21例患者获得13个月～7年随访,平均随访时间4.8年.16例患者术后跛行程度明显改善;通过软组织松解可显著纠正下肢不等长,有效减少手术截骨长度.术后Harris评分平均89.6分.患者术后未见脱位、感染及假体松动.结论 适当的软组织松解和平衡可使高位髋臼重建于真臼,有效地恢复髋关节的形态和功能,获得满意的近期效果.     

重症手足口病患儿外周血炎性因子、神经元特异性烯醇化酶与中枢神经特异性S100β蛋白水平变化

目的研究重症手足口病（HFMD）患儿外周血白细胞介素（IL）-6、IL-10、IL-17、神经元特异性烯醇化酶、中枢神经特异性蛋白S100β的变化。 方法以60例手足口病患儿为研究对象,其中轻症患儿30例（轻症组）和重症30例（重症组）,另选取30例健康儿童为对照组;采用双抗体夹心酶联免疫吸附实验检测各组患儿外周血IL-6、IL-10、IL-17、NSE和S100β水平。 结果与对照组、轻症患儿相比,重症手足口病患儿外周血IL-6、IL-10、IL-17水平均显著升高,差异有统计学意义（重症组vs.对照组：t = 9.83、8.56、7.85,P = 0.043、0.019、0.011;重症组vs.轻症组：t = 5.84、4.95、6.59,P = 0.023、0.032、0.024）。与对照组患儿相比,轻症患儿外周血IL-6、IL-10、IL-17水平稍有升高,但差异无统计学意义（t = 0.53、1.03、0.38,P = 0.292、0.445、0.362）。与对照组和轻症组相比,重症组患儿外周血NSE和S100β的水平显著升高,差异有统计学意义（重症组vs.对照组：t = 11.39、9.25,P = 0.018、0.016;重症组vs.轻症组：t = 5.44、6.3,P = 0.031、0.028）。与对照组相比,轻症患儿外周血NSE、S100β均有升高,但无统计学意义（t = 1.38、1.89,P = 0.098、0.142）。 结论手足口病患儿外周血IL-6、IL-10、IL-17、NSE和S100β水平升高,可提示病情严重程度;临床监测以上指标变化,可早期发现重症患者,尽早治疗。     

Early total hip arthroplasty for severe displaced acetabular fractures

Objective ： To investigate the effect of early total hip arthroplasty for severe displaced acetabular fractures. Methods： Total hip arthroplasty was performed on 17 cases of severe fracture of the acetabulum from 1997 to 2003. The mean follow-up was 2.1 years（ 1-6 years） and the average period from fracture to operation was 8 days （5-21 day）. The average age of the patients was 53 years （ 26-69 years）. Restdts： At the final follow-up the Harris hip score averaged 82（69-100） points and 15 cases have got a good outcome. There was one case of heterotopic bone formation. There were no radiographic evidences of lateloosening of the prosthesis. One patient had severe central displacement of the cup. Conclusions： In patients with severe displaced acetabular fractures, particularly in elderly patients, early total hip arthroplasty is probably an alternative efficient way to achieve a painless and stable hip.     

Polyarteritis nodosa type vasculitis in a patient with familial Mediterranean fever treated with cyclosporin A

Patients with amyloidosis secondary to familial Mediterranean fever (FMF) are known to tolerate cyclosporin A poorly. We report a case of severe cyclosporin toxicity in a patient with FMF amyloidosis who underwent kidney transplantation. The clinical syndrome consisted of severe gastrointestinal, neuromuscular, and psychiatric disturbances. Histological examination of the transplanted kidney revealed vasculitis of the polyarteritis nodosa type. We hypothesize that FMF patients are more vulnerable to the acute vascular toxicity of cyclosporin due to defective inhibition of complement activation, leading to a widespread vasculitis of the polyarteritis nodosa type.     

髌股关节置换术治疗严重髌股关节炎的中远期疗效

目的 探讨髌股关节置换术治疗单纯髌股关节炎的临床意义及中远期疗效.方法 1991年1月至1999年7月,应用自行研制的人工髌股关节假体(Y-L-Q型)行髌股关节置换术治疗严重的单纯髌股关节炎并获得随访患者39例48膝,男6例6膝,女33例42膝;年龄38～68岁,平均54.4岁.常规于术后3个月、半年、1年及之后每年门诊随访,摄膝关节正侧位、负重位及髌骨轴位X线片,检查关节活动度,询问患者症状,根据自行制定的疗效评价标准进行评价.结果 随访时间8～16年,平均12.7年.末次随访时髌股关节置换的疗效为优29膝、良12膝、可2膝、差5膝,优良率为85.4%.随访期间无假体松动或断裂,无髌骨骨折.3例5膝(10.4%)因病情持续进展而行全膝关节置换术,两次手术的间隔时间为7～12年,平均9.3年.结论 应用自行设计的人工髌股关节假体(Y-L-Q型)行髌股关节置换术是治疗单纯髌股关节炎的一种简单有效的方法,能改善髌前痛症状,推迟全膝关节置换术时间.提高假体生存率的关键是适应证的准确选择和熟练的手术操作.     

Utility of Tolvaptan in the Perioperative Management of Severe Hyponatremia During Liver Transplantation: A Case Report

Severe hyponatremia can complicate the pretransplantation management of patients with decompensated cirrhosis while they await liver transplantation. Before the liver transplant, it is critical to correct severe hyponatremia to an appropriate level to reduce the risks of perioperative complications such as central pontine myelinolysis, cerebral edema, and seizures. Vasopressin receptor antagonists, and in particular tolvaptan, offer a therapeutic modality that can correct severe refractory hyponatremia in a timely and predictable manner before liver transplantation. In this case report, we describe a patient with decompensated cirrhosis and severe hyponatremia in whom administration of tolvaptan led to an optimal correction of preoperative severe hyponatremia and allowed for successful liver transplantation with no associated postoperative complications. In light of the increasing pretransplantation disease severity and higher risk of severe hyponatremia, the use of tolvaptan in the pretransplant period may gain increasing importance as a therapeutic intervention for maintaining peritransplant sodium homeostasis.     

Sildenafil Monotherapy to Treat Portopulmonary Hypertension Before Liver Transplant

Portopulmonary hypertension (PPHTN) is a rare complication of liver cirrhosis. Patients with severe PPHTN are contraindicated for liver transplant because of the associated risk of intraoperative acute right heart failure during reperfusion phase or massive volume infusion. Therefore, it has been recommended that patients with moderate to severe PPHTN undergo medical treatment to lower the pulmonary artery pressure before undergoing transplant. Herein, we report 3 patients with severe PPHTN who underwent sildenafil monotherapy before living donor liver transplant. None of the patients experienced associated adverse effects during sildenafil treatment, and the pulmonary artery pressure was effectively reduced before transplant. The first patient was diagnosed during anesthesia prior to transplant, and the mean pulmonary artery pressure was reduced by 34% after treatment. The second and third patients were followed-up with echography, and the estimated pulmonary artery systolic pressure were reduced by 34% and 47%, respectively. Pretransplant right heart catheterization also confirmed the reduction of the mean pulmonary artery pressure. Intraoperative hemodynamic parameters were stable, and the 3 patients were discharged uneventfully. After transplant, sildenafil was discontinued, and all patients remained in a stable clinical and functional status during follow-up.     

Elevated S100B levels do not correlate with the severity of encephalopathy during sepsis

Background: Sepsis-associated encephalopathy (SAE) is defined as a diffusecerebral dysfunction induced by the systemic response to infectionwithout any clinical or laboratory evidence of direct infectiousinvolvement of the central nervous system. The astroglial proteinS100B has been used as a marker of severity of brain injuryand as a prognostic index in trauma patients and cardiac arrestsurvivors. We measured S100B serum levels in patients with severesepsis to investigate if the severity of SAE correlated withan increase in S100B levels. Methods: Twenty-one patients, with a diagnosis of severe sepsis, wereincluded in this study. S100B levels were measured at intensivecare unit (ICU) admission, 72 h and 7 days after admission.Their association with markers of brain dysfunction such asGlasgow coma scale (GCS), and EEG, and with sepsis-related organfailure assessment score (SOFA) and ICU mortality was investigated. Results: Fourteen patients had elevated S100B levels. The levels didnot correlate with GCS at admission, EEG pattern, or SOFA scores.Also, S100B levels did not differ between patients who recoveredneurologically and those who did not (P = 0.62). Conclusions: In severe sepsis, an increase in S100B does not allow the physiciansto distinguish patients with severe impairment of consciousnessfrom those with milder derangements or to prognosticate neurologicalrecovery.     

Outcomes of 50 Cases of Pediatric Liver Transplantation for Intrapulmonary Shunt While Considering the Deteriorated Prognosis of Severe Intrapulmonary Shunt Patients

BackgroundIntrapulmonary shunt (IPS) is recognized in 10% of chronic liver disease patients. Liver transplantation (LT) is associated with a high risk of morbidity and mortality in patients with IPS.Patients and methodsOf 519 pediatric LT cases between November 2005 and October 2018, 50 patients with IPS were enrolled in this study. The patients were divided into 3 groups, according to the shunt ratio, calculated by scintigraphy: mild (15%-20%, n = 26), moderate (20%–40%, n = 19), and severe (> 40%, n = 5). We compared the patients’ characteristics before LT and the outcomes of LT between these groups.ResultsThe major original disease resulting in LT in the mild and moderate groups was biliary atresia (73.1% and 52.6%, respectively), while that in the severe group was congenital portosystemic shunt (60%). The median ages at LT were 7.5, 6.1, and 8.3 years in the mild, moderate, and severe groups, respectively. All of the mild and moderate IPS patients lived; however, 3 patients with severe IPS (60.0%) died within 3 months. The shunt ratios of the mild and moderate IPS patients normalized within 2 years after LT, while the 2 surviving severe IPS patients showed a slight improvement. The autopsy findings of the lung in 1 deceased severe IPS patient showed medial hypertrophy and proliferation of intimal cells of the pulmonary arteries, suggesting a diagnosis of portopulmonary hypertension.ConclusionsLT can be safely performed for mild and moderate IPS patients; however, LT for severe IPS patients should be carefully indicated because concomitant portopulmonary hypertension may be masked by IPS.     

Some contemporary ethical considerations related to organ transplantation

With the increasing number of transplantable organs and tissues, as well as improvements in transplantation results, has come a severe shortage of organ donors. Consequently, new ethical dilemmas, related to the fair allocation of available organs and the use of alternative sources of donor organs, are of growing concern. Establishing fair allocation priorities is a serious problem in organ transplantation. Ethically, they should be defined by society as a whole rather than exclusively by the medical profession. Proposed solutions for the organ donor shortage, each with their unique ethical constraints, include the use of related donors, partial organ transplantation, cell transplantation using fetal tissue, and the use of animal organs (xenotransplantation). Commerical trading in donor organs must be regarded as an unethical activity rather than an ethical dilemma since the donors are motivated by monetary rather than by humanitarian reasons. These ethical dilemmas could be largely avoided by an effective reduction in the severe shortage of postmortal organ donations.     

Primary pulmonary hypertension in pregnancy; a role for novel vasodilators

We describe the case of a 28-week pregnant woman presentingwith severe primary pulmonary hypertension (PPH). She had anelective Caesarean section under general anaesthesia at 32 weeksgestation. Pulmonary artery pressures (PAP) measured from apulmonary artery catheter before anaesthesia were in excessof 100 mm Hg. Intraoperative nitric oxide was used to reducePAP. After the delivery of a healthy infant PAP was controlledwith nebulized iloprost and a prostacyclin infusion. Seven dayslater she was discharged from intensive care taking an oralcalcium antagonist and warfarin. She developed intractable rightheart failure and died 14 days after delivery. Despite increasingexperience in the use of drugs to reduce PAP, the clinical courseof pregnancy complicated by severe PPH is usually fatal. Br J Anaesth 2001; 87: 295–8     

重症急性胰腺炎的液体复苏与器官保护

重症急性胰腺炎(SAP)的发病率逐年增高,并且起病凶险,致残率、病死率高。重症急性胰腺炎的治疗是一种涉及多个学科,多种手段的综合治疗。不同的学科从不同的角度,有着不同的治疗理念,并且对疾病不同阶段的认识也不同。但在其非手术治疗手段中,有效的液体复苏与脏器保护对降低重症急性胰腺炎的病死率起到非常重要的作用。本文从重症医学的角度,归纳总结了在重症急性胰腺炎治疗过程中,液体复苏治疗及器官保护治疗的最新理念及治疗进展。以及对目前的治疗方法中,存在的问题进行了进一步的剖析。     

Modified Masquelet Technique Assisting 3D Printed Elbow Prosthesis for Open Elbow Fracture with Severe Bone Defect: A Case Report and Technique Note

BackgroundInternal fixation for severe open articular bone defects is sometimes ineffective or dangerous. In the emergency stage, radical debridement and infection prevention are demanded to provide a good tissue base and the space‐occupying effect to provide enough necessary space to avoid soft‐tissue contraction for the reconstruction. In addition, the 3D printing technology makes individual limb reconstruction a reality.Case PresentationHere, we present a 31‐year‐old patient with an open fracture and severe bone defect of his left elbow caused by traffic accident, classified as Gustilo–Anderson IIIB. We adopted aggressive debridement and insertion of polymethyl methacrylate (PMMA) to prevent the infection and temporarily construct the bone defect in the emergency stage. Secondly, the total elbow arthroplasty was performed using a unique three‐dimensional (3D) printed prosthesis to reconstruct the elbow joint. During the follow‐up, the elbow movement function was satisfactory.ConclusionsThe modified Masquelet technique assisting 3D printing of personalized elbow joint makes the satisfactory functional reconstruction for open high‐energy injuries come true. It could be promoted for the similar surgery of other open joints fractures with severe bone defects.     

Prevention of stress ulcer bleeding with cimetidine in severe burns

This paper presents clinical observations on the preventive effect of cimetidine for stress ulcer bleeding in severe burns. It shows that gastrointestinal bleeding after severe burn is significantly reduced, and the incidence of acute gastro-duodenal ulcer lowered by administration of cimetidine.     

Conversion to tacrolimus after liver transplantation

We have reviewed our experience with conversion to tacrolimus after 435 liver transplantations. Tacrolimus was administered as a rescue agent in 33 patients until October 1993. Indications for rescue therapy were: cholestatic forms of severe, steroid-resistant cellular rejection (n=8), OKT3-resistant cellular rejections (n=6), cellular rejections in patients suffering from cyclosporin malabsorption (n=4), late onset cellular rejections (n=4), early chronic rejections (n=3), and chronic vascular or ductopenic rejections (n=8). Response was evident in 29 of the 33 patients (88%), whereas 4 patients (12%) were nonresponsive. Patient and graft survival were 76% and 70%, respecitively. Graft loss with or without patient death occurred in three of eight patients suffering from severe, steroid-resistant cellular rejection, in two of six patients with OKT3-resistant cellular rejections, and in five of eight patients undergoing chronic rejection. In severe steroid-resistant cellular rejection, successful tacrolimus rescue therapy corresponded to a significantly lower total serum bilirubin than unsuccessful therapy (12.0±5.6 mg% vs 29.7±5.9 mg%, P(0.05). We conclude that tacrolimus rescue therapy is a safe and efficient alternative for high-risk cases that do not respond to conservative treatment. In severe, steroid-resistant cellular rejection and in chronic ductopenic rejection, conversion to tacrolimus is beneficial only in a limited number of cases. A predictive parameter, which total serum bilirubin may prove to be in severe, steroid-resistant cellular rejection, is needed to select those cases that might benefit more from retransplantation than from conversion to tacrolimus.     

血液灌流联合血液透析治疗重度有机磷农药中毒40例临床分析

目的 分析血液灌流联合血液透析治疗重度有机磷农药中毒疗效和安全性.方法 回顾性分析2006年1月至2009年4月收治的40例重度有机磷农药中毒患者行血液灌流联合血液透析治疗的临床资料.结果 40例重度有机磷农药中毒患者行血液灌流联合血液透析治疗后,有36例痊愈,4例死亡.40例患者中有2例出现中间综合征,继续多次行血液灌流联合血液透析治疗后痊愈.40例患者中有1例患者因原有胃黏膜损伤而出现消化道出血.结论 血液灌流联合血液透析治疗重度有机磷农药中毒疗效可靠安全、能提高抢救成功率、减少中毒后遗症,且安全性好.     

Effect of intravenous infusion on development of pulmonary oedema after inhalation injury

Last year, after a systematic search of pathological and pathophysiological changes of inhalation injury in dogs, we recorded severe pulmonary oedema as early as 2 h postburn (the earliest monitoring time designed in experiment) on dogs inflicted with both body surface and severe respiratory burns without any fluid replacement during the whole course of experiment. In an analysis of cases admitted into our burn centre in the past ten years, we also found that there was no definite relationship between the incidence and severity of pulmonary oedema occurring in severe burn patients and the amount of fluid infused in the early burn phase. These facts led us to the following experiment designed to study the effect of intravenous infusion on development of pulmonary oedema after severe burns complicated with inhalation injuries.